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Category:NRC Forms (Blank)
MONTHYEARML22192A1972022-07-11011 July 2022 NRC Form 446 - Request for Approval of Official Foreign Travel by Non-Government Personnel (*Must Be Completed 30 Days Prior to Travel) ML21148A2422021-05-28028 May 2021 NRC Form 149 - Ocfo Invitational Traveler Request Form ML20339A6732021-01-12012 January 2021 NRC Form 529 - Dispute of Fees-for-Service Charges in Accordance with Title 10 of the Code of Federal Regulations (10 CFR) 170.51 ML12164A7272020-01-31031 January 2020 NRC Form 313A (Amp), Authorized Medical Physicist or Ophthalmic Physicist, Training, Experience and Preceptor Attestation (10 CFR 35.51, 35.57(a)(3), and 35.433). (01-2020) ML12164A7282020-01-31031 January 2020 NRC Form 313A (Anp), Authorized Nuclear Pharmacist Training, Experience, and Preceptor Attestation (10 CFR 35.55). (01-2020) ML12164A7332020-01-31031 January 2020 NRC Form 313A (Aud), Authorized User Training, Experience, and Preceptor Attestation (for Uses Defined Under 35.100, 35.200, and 35.500) (10 CFR 35.57, 35.190, 35.290, and 35.590). (01-2020) ML12164A7362020-01-31031 January 2020 NRC Form 313A (Aus), Authorized User Training, Experience, and Preceptor Attestation (for Uses Defined Under 35.400 and 35.600) (10 CFR 35.57, 35.490, 35.491, and 35.690). (01-2020) ML12164A7412020-01-31031 January 2020 NRC Form 313A (Aut), Authorized User Training, Experience, and Preceptor Attestation (for Uses Defined Under 35.300)(10 CFR 35.57, 35.390, 35.392, 35.394, and 35.396). (01-2020) ML12164A7422020-01-31031 January 2020 NRC Form 313A (Rso), Radiation Safety Officer or Associate Radiation Safety Officer Training, Experience, and Preceptor Attestation (10 CFR 35.57, 35.50). (01-2020) ML13083A1032019-10-31031 October 2019 NRC Form 361N - Non-Power Reactor (NPR) Event Notification Worksheet ML13083A0722019-09-30030 September 2019 NRC Form 313 - Application for Materials License ML13083A0192019-07-31031 July 2019 NRC Form 7 - Application for NRC Export or Import License, Amendment, Renewal, or Consent Request(S) ML13083A1232019-07-31031 July 2019 NRC Form 396 - Certification of Medical Examination by Facility Licensee ML13083A1272019-07-31031 July 2019 NRC Form 398 - Personal Qualification Statement -- Licensee ML13083A1742019-07-31031 July 2019 NRC Form 526 - Certification of Small Entity Status for the Purposes of Annual Fees Imposed Under 10 CFR Part 171 (Effective July 16, 2019) ML13083A1762019-05-31031 May 2019 NRC Form 531 - Request for Taxpayer Identification Number ML13083A2502019-04-30030 April 2019 NRC Form 664 - General Licensee Registration ML19231A2062019-01-31031 January 2019 NRC Form 527 - Request for Information Related to Contractor Charges -- in Accordance with 10 CFR 170.51 ML16025A0332018-12-31031 December 2018 NRC Form 405F - List All Owners, Officers, Directors, and Executive Personnel (Oodep'S) ML13083A1372018-10-31031 October 2018 NRC Form 426 - Authorization to Publish a Manuscript in the NUREG Series ML13083A0942018-06-30030 June 2018 NRC Form 354 - Data Report on Spouse ML13083A1422018-05-31031 May 2018 NRC Form 445 - Request for Approval of Official Foreign Travel ML13083A1522018-04-30030 April 2018 NRC Form 483 - Registration Certificate -- in Vitro Testing with Byproduct Material Under General License ML13083A1072018-04-30030 April 2018 NRC Form 366A - Licensee Event Report (LER) Continuation Sheet ML13083A1062018-04-30030 April 2018 NRC Form 366 - Licensee Event Report (LER) ML13083A2952018-04-30030 April 2018 NRC Form 740M - Concise Note ML13083A2972018-04-30030 April 2018 NRC Form 742 - Material Balance Report ML13083A2982018-04-30030 April 2018 NRC Form 742C - Physical Inventory Listing ML13083A2962018-04-30030 April 2018 NRC Form 741 - Nuclear Material Transaction Report ML13083A2442018-02-28028 February 2018 NRC Form 653 - Transfers of Industrial Devices Report (to General Licensees) ML13083A1082018-02-28028 February 2018 NRC Form 366B - Licensee Event Report (LER) ML13114A5072017-12-31031 December 2017 NRC Form 782 - Complaint Form ML13083A3292017-12-31031 December 2017 NRC Form 781 - Sbcr Compliance Review Part a ML13083A1792017-11-30030 November 2017 NRC Form 536 - Operator Licensing Examination Data ML13083A0172017-10-31031 October 2017 NRC Form 5 - Occupational Dose Record for Monitoring Period ML13083A0052017-10-31031 October 2017 NRC Form 4 - Cumulative Occupational Dose History ML13083A0182017-10-31031 October 2017 NRC Form 64 - Travel Voucher ML13083A0592017-10-31031 October 2017 NRC Form 241 - Report of Proposed Activities in Non-Agreement States, Areas of Exclusive Federal Jurisdiction, or Offshore Waters ML14211A1652017-09-30030 September 2017 NRC Form 749 - Manual License Verification Report ML13083A0022017-08-31031 August 2017 NRC Form 3 - Notice to Employees ML13083A2372017-07-31031 July 2017 NRC Form 629 - Authorization for Payment by Credit Card ML13083A0502017-05-31031 May 2017 NRC Form 212 - Qualifications Investigation Professional, Technical, and Administrative Positions ML13083A0852017-03-31031 March 2017 NRC Form 327 - Special Nuclear Material (SNM) and Source Material (SM) Physical Inventory Summary Report ML19231A1992017-03-31031 March 2017 NRC Form 787 - Freedom of Information Act - User Survey ML13083A0792017-02-28028 February 2017 NRC Form 314 - Certificate of Disposition of Materials ML13083A1802017-01-31031 January 2017 NRC Form 540 - NRC Uniform Low-Level Radioactive Waste Manifest Shipping Paper ML13083A1812017-01-31031 January 2017 NRC Form 540A - Uniform Low-Level Radioactive Waste Manifest Shipping Paper (Continuation) ML13083A1822017-01-31031 January 2017 NRC Form 541 - Uniform Low-Level Radioactive Waste Manifest Container and Waste Description ML13083A0282017-01-31031 January 2017 NRC Form 136 - Security Termination Statement ML13083A1832017-01-31031 January 2017 NRC Form 541A - Uniform Low-Level Radioactive Waste Manifest Container and Waster Description (Continuation) 2022-07-11
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NRC FORM 313 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0120 EXPIRES: 09/30/2019 (09-2019) Estimated burden per response to comply with this mandatory collection request: 4.3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br />. Submittal of the 10 CFR 30, 32, application is necessary to determine that the applicant is qualified and that adequate procedures exist to protect the 33, 34, 35, 36, public health and safety. Send comments regarding burden estimate to the Information Services Branch (T-6 A10M),
37, 39, and 40 APPLICATION FOR U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, MATERIALS LICENSE and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0120), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.
INSTRUCTIONS: SEE THE CURRENT VOLUMES OF THE NUREG-1556 TECHNICAL REPORT SERIES (CONSOLIDATED GUIDANCE ABOUT MATERIALS LICENSES) FOR DETAILED INSTRUCTIONS FOR COMPLETING THIS FORM: http://www.nrc.gov/reading-rm/doc-collections/nuregs/staff/sr1556/. SEND TWO COPIES OF THE COMPLETED APPLICATION TO THE NRC OFFICE SPECIFIED BELOW.
APPLICATION FOR DISTRIBUTION OF EXEMPT PRODUCTS FILE APPLICATIONS WITH: IF YOU ARE LOCATED IN:
MATERIALS SAFETY LICENSING BRANCH ILLINOIS, INDIANA, IOWA, MICHIGAN, MINNESOTA, MISSOURI, OHIO, OR WISCONSIN, SEND DIVISION OF MATERIAL SAFETY, STATE, TRIBAL AND RULEMAKING PROGRAMS APPLICATIONS TO:
OFFICE OF NUCLEAR MATERIALS SAFETY AND SAFEGUARDS U.S. NUCLEAR REGULATORY COMMISSION MATERIALS LICENSING BRANCH WASHINGTON, DC 20555-0001 U.S. NUCLEAR REGULATORY COMMISSION, REGION III 2443 WARRENVILLE ROAD, SUITE 210 ALL OTHER PERSONS FILE APPLICATIONS AS FOLLOWS: LISLE, IL 60532-4352 IF YOU ARE LOCATED IN: IF YOU ARE LOCATED IN:
ALABAMA, CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA, FLORIDA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, COLORADO, HAWAII, IDAHO, KANSAS, GEORGIA, KENTUCKY, MAINE, MARYLAND, MASSACHUSETTS, NEW HAMPSHIRE, LOUISIANA, MISSISSIPPI, MONTANA, NEBRASKA, NEVADA, NEW MEXICO, NORTH NEW JERSEY, NEW YORK, NORTH CAROLINA, PENNSYLVANIA, PUERTO RICO, DAKOTA, OKLAHOMA, OREGON, PACIFIC TRUST TERRITORIES, SOUTH DAKOTA, TEXAS, RHODE ISLAND, SOUTH CAROLINA, TENNESSEE, VERMONT, VIRGINIA, VIRGIN UTAH, WASHINGTON, OR WYOMING, ISLANDS, OR WEST VIRGINIA, SEND APPLICATIONS TO: SEND APPLICATIONS TO:
LICENSING ASSISTANCE TEAM NUCLEAR MATERIALS LICENSING BRANCH DIVISION OF NUCLEAR MATERIALS SAFETY U.S. NUCLEAR REGULATORY COMMISSION, REGION IV U.S. NUCLEAR REGULATORY COMMISSION, REGION I 1600 E. LAMAR BOULEVARD 2100 RENAISSANCE BOULEVARD, SUITE 100 ARLINGTON, TX 76011-4511 KING OF PRUSSIA, PA 19406-2713 PERSONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO THE U.S. NUCLEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS AND USE LICENSED MATERIAL IN STATES SUBJECT TO U.S. NUCLEAR REGULATORY COMMISSION JURISDICTIONS.
- 1. THIS IS AN APPLICATION FOR (Check appropriate item) 2. NAME AND MAILING ADDRESS OF APPLICANT (Include zip code)
A. NEW LICENSE B. AMENDMENT TO LICENSE NUMBER C. RENEWAL OF LICENSE NUMBER
- 3. ADDRESS WHERE LICENSED MATERIALS WILL BE USED OR POSSESSED 4. NAME OF PERSON TO BE CONTACTED ABOUT THIS APPLICATION BUSINESS TELEPHONE NUMBER BUSINESS CELLULAR TELEPHONE NUMBER BUSINESS E-MAIL ADDRESS SUBMIT ITEMS 5 THROUGH 11 ON 8-1/2 X 11" PAPER. THE TYPE AND SCOPE OF INFORMATION TO BE PROVIDED IS DESCRIBED IN THE LICENSE APPLICATION GUIDE.
- 5. RADIOACTIVE MATERIAL 6. PURPOSE(S) FOR WHICH LICENSED MATERIAL WILL BE USED.
- a. Element and mass number; b. chemical and/or physical form; and c. maximum amount 7. INDIVIDUAL(S) RESPONSIBLE FOR RADIATION SAFETY PROGRAM AND THEIR TRAINING AND which will be possessed at any one time. EXPERIENCE.
- 8. TRAINING FOR INDIVIDUALS WORKING IN OR FREQUENTING RESTRICTED AREAS. 9. FACILITIES AND EQUIPMENT.
- 10. RADIATION SAFETY PROGRAM. 11. WASTE MANAGEMENT.
- 12. LICENSE FEES (Fees required only for new applications, with few exceptions*)
(See 10 CFR 170 and Section 170.31)
FEE CATEGORY AMOUNT ENCLOSED $
- Amendments/Renewals that increase the scope of the existing license to a new or higher fee category will require a fee.
PER THE DEBT COLLECTION IMPROVEMENT ACT OF 1996 (PUBLIC LAW 104-134), YOU ARE REQUIRED TO PROVIDE YOUR TAXPAYER IDENTIFICATION NUMBER. PROVIDE THIS INFORMATION BY COMPLETING NRC FORM 531: https://www.nrc.gov/reading-rm/doc-collections/forms/nrc531info.html.
- 13. CERTIFICATION. (Must be completed by applicant) THE APPLICANT UNDERSTANDS THAT ALL STATEMENTS AND REPRESENTATIONS MADE IN THIS APPLICATION ARE BINDING UPON THE APPLICANT.
THE APPLICANT AND ANY OFFICIAL EXECUTING THIS CERTIFICATION ON BEHALF OF THE APPLICANT, NAMED IN ITEM 2, CERTIFY THAT THIS APPLICATION IS PREPARED IN CONFORMITY WITH TITLE 10, CODE OF FEDERAL REGULATIONS, PARTS 30, 32, 33, 34, 35, 36, 37, 39, AND 40, AND THAT ALL INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT TO THE BEST OF THEIR KNOWLEDGE AND BELIEF.
WARNING: 18 U.S.C. SECTION 1001 ACT OF JUNE 25, 1948 62 STAT. 749 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION.
CERTIFYING OFFICER -- TYPED/PRINTED NAME AND TITLE SIGNATURE DATE FOR NRC USE ONLY TYPE OF FEE FEE LOG FEE CATEGORY AMOUNT RECEIVED CHECK NUMBER COMMENTS APPROVED BY DATE NRC FORM 313 (09-2019)